Emergency Department Care Manager - Case Management

Summary:

The Emergency Department (ED) Care Manager (CM) is responsible for establishing, coordinating, and maintaining the process to increase patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum for the ED. The ED Care Manager collaborates with the patient and/or family, multidisciplinary team, physicians, community partners, and payers to ensure the patient’s progress and level of care are appropriately determined. The ED Care Manager has well-developed knowledge and skill in patient status determination in the inpatient and outpatient settings and collaborates with other care managers, social workers, Patient Access, physicians, and administrative leadership in the ED to determine the appropriate level of care. The ED CM also has a robust understanding of services and resources outside of the hospital that would be of benefit to the patient and initiates referrals as indicated. This work includes patient assessment and management, resource management, identifying patients appropriate for admission, observation or outpatient status, care facilitation, discharge planning with referrals to all levels of care, and other duties related to the defined population.

CHRISTUS Santa Rosa Hospital - Westover Hills (CSRH-WH) is a 150-bed hospital serving the fastest growing area of San Antonio. Specialized care includes orthopedic and surgical services, ICU, women’s services, a newborn nursery, comprehensive cardiovascular care from diagnostics to open heart surgery, vascular lab, sleep center, emergency services, the CHRISTUS Weight Loss Institute, wound care, rehabilitation, and more. The campus also boasts an Outpatient Imaging Center and three medical plazas, one of which houses our CHRISTUS Santa Rosa Family Medicine Residency Program and CHRISTUS Santa Rosa Family Health Center.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Uses approved criteria to conduct patient assessment and admission clinical review to ensure appropriateness of setting and timely implementation of the plan of care.
• Performs review of anticipated admissions, placements in Observation status and discharges using evidence-based criteria set for appropriate level of care assignment.
• Screens appropriateness of admission including observation versus inpatient status utilizing MCG and/or InterQual criteria.
• Educates ED physicians and nurses about medical necessity and admission criteria.
• Initiates and maintains communication and collaboration with physicians and other members of the treatment team to develop, implement, and evaluate the plan of care for the patient.
• Provides education to providers and staff on documentation needs and opportunities to support the appropriate level of care and the treatment being provided.
• Initiates prior authorization process when indicated for post-ED referrals and services.
• Utilizes financial and insurance resources of the patient to maximize the patient’s health care benefit.
• Intervenes with physicians and other health care providers regarding clinical and utilization issues to ensure optimal patient outcomes.
• Communicates with third party payors and/or review organizations as necessary and provides information to both government and private payors in accordance with regulation and/or contract requirements.
• Escalates to physician advisor when unable to resolve discrepancies with the attending physician.
• Provides early identification and intervention of ED patients at risk for readmission.
• Manages high-utilization patients and works to find alternatives for care to frequent ED visits.
• Provides identification of patients for whom standard of care treatments could be safely rendered at home or other lower level of care setting.
• Plans for discharges from the ED for patients who do not require admission to include arranging for Home Health, DME, placement, and community resources as they relate to social determinants of health.
• Provides patient and family education and counseling about existing health problem related care.
• Utilizes high risk screening criteria to make appropriate community and post-ED referrals
• Anticipates barriers/variances to the delivery of care and intervenes as necessary.
• Coordinates and facilitates patient progression throughout the continuum.
• Collaborates with all members of the interdisciplinary team to facilitate appropriate care coordination and care delivery.
• May assist with coordination of patient transfers to other inpatient facilities when indicated
• Documents all CM assessments and interventions in the medical record.
• Must have familiarity with evidence-based criteria sets
• Must demonstrate proficiency in computer skills - Windows, Instant Messaging, Microsoft Suite including Word, Excel, and Outlook
• Competent in prior authorization functions including application of criteria and timelines.
• Have the ability to analyze clinical information and accurately apply clinical criteria.
• Proficient in medical and managed care terminology.
• Has knowledge of and competence in use of prior authorization software.
• Has ability to multitask between computer, fax, and multi-line phone requests.

Requirements:

A. Education/Skills

• Associate's Degree in Nursing required.
• Bachelor’s Degree in nursing or healthcare related field preferred.

B. Experience

• 3+ years of relevant clinical case/care management experience in the acute care setting required.

C. Licenses, Registrations, or Certifications

• RN License in state of employment or compact.
• Case Manager certification preferred.

Work Schedule:

Varies

Work Type:

Full Time

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https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf

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